Citation Nr: 1432167 Decision Date: 07/17/14 Archive Date: 07/22/14 DOCKET NO. 10-27 774 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUE Entitlement to an initial rating higher than 10 percent for bilateral plantar fasciitis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Dean, Associate Counsel INTRODUCTION The Veteran had active military service from June 1991 to June 1994 and from April 2002 to April 2004. He appealed to the Board of Veterans' Appeals (Board/BVA) from a December 2004 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO), which granted his claim of entitlement to service connection for bilateral plantar fasciitis and assigned a 10 percent disability rating retroactively effective from April 30, 2004, so back to the day after his military service ended. He appealed for a higher initial rating. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (when a Veteran appeals his initial rating, VA must consider whether to "stage" the rating to compensate him for times since the effective date of the award when the disability may have been more severe than at others). In support of his claim, the Veteran testified at a hearing in August 2011 at the Board's offices in Washington, DC (Central Office (CO) hearing). A transcript of the hearing is in the claims file, so of record. In November 2011 and again in February 2013, the Board remanded the claim to the RO via the Appeals Management Center (AMC) for additional development and consideration. In August 2013 the Board issued a decision denying the claim, and in response the Veteran appealed to the U.S. Court of Appeals for Veterans Claims (Court/CAVC). In granting a March 2014 Joint Motion for Partial Remand, the Court partially vacated (set aside) the Board's decision to the extent it had denied an initial disability rating higher than 10 percent for the Veteran's bilateral plantar fasciitis. The Court remanded this claim to the Board for further proceedings consistent with the motion. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The Veteran has "moderate" foot disability on account of his right and left foot plantar fasciitis, especially taking into consideration his pain on use of his feet, reported regular use of a cane, and lack of relief from orthotics. CONCLUSIONS OF LAW 1. The criteria are met for an initial 10 percent rating, but no higher, for the right foot plantar fasciitis. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Codes (DCs) 5276-84 (2013). 2. The criteria are also met however for a separate 10 percent initial rating, but no higher, for the left foot plantar fasciitis. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.71a, DCs 5276-84 (2013). REASONS AND BASES FOR FINDING AND CONCLUSIONS I. Standard of Review In deciding this claim, the Board has reviewed all of the evidence in the claims file, both the physical claims file and electronic ("Virtual VA") portion of the file, and has an obligation to provide an adequate statement of reasons or bases supporting this decision. See 38 U.S.C.A. § 7104(d)(1) (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). But while the Board must review the entire record, it need not discuss each and every piece of evidence, certainly not in exhaustive detail. See id. The analysis below therefore focuses only on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board addresses its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all relevant evidence, so both the medical and lay evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. When the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must weigh against a claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). II. The Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), sets forth VA's duties to notify and assist a claimant in substantiating a claim for VA benefits. The VCAA was codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, and the implementing regulations were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative of any information and medical or lay evidence not of record that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In order to satisfy its duty to notify the claimant under the VCAA, the United States Court of Appeals for Veterans Claims (Court/CAVC) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will obtain; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Ideally, VCAA notice should be provided prior to an initial decision on a claim by the RO as the Agency or Original Jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if notice was not provided prior to initially adjudicating a claim, or if provided and it was inadequate or incomplete, the issuance of a fully compliant VCAA notification followed by readjudication of the claim, including in a statement of the case (SOC) or supplemental SOC (SSOC), is sufficient to "cure" the timing defect in the provision of the notice because the intended purpose of the notice is still preserved, not frustrated, since the Veteran is still given meaningful opportunity to participate effectively in the adjudication of his claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006). In claims for increased ratings for disabilities that already have been determined service connected in years past, the Court has held that in order to satisfy the first notice element VA must notify the claimant that he needs to provide or request VA to obtain medical or lay evidence demonstrating a worsening or increase in severity of the disability at issue. Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 97-103 (2010) (Vasquez-Flores III); Vazquez-Flores v. Peake, 22 Vet. App. 37, 43 (2008) (Vasquez-Flores I), overruled in part sub. nom. Vasquez-Florez/Wilson v. Shinseki, 580 F.3d 1270, 1280-81 (Fed. Cir. 2009) (Vasquez-Flores II). Further, the claimant must be notified that a disability rating will be determined by applying relevant Diagnostic Codes (DCs), which typically provide for a range in severity of a particular disability from 0 percent, i.e., noncompensable, to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment. Id. Finally, the notice must provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Id. Except when VCAA notice as to how to substantiate a claim is not provided at all, it is the claimant's burden to show that he was prejudiced by any deficiency in the notice provided. See Vazquez-Flores, 24 Vet. App. at 106-107. And VA is not required to apprise him of alternative DCs or daily-life evidence, only instead provide what amounts to "generic" notice. Here, prior to the December 2004 rating decision at issue, August and October 2004 letters satisfied all notice elements under the VCAA. The letters informed the Veteran of how VA generally evaluates service-connected disabilities, provided examples of the types of evidence he could submit in support of his claim, and notified him of his and VA's respective responsibilities in obtaining relevant records and other evidence on his behalf. Accordingly, the duty to notify has been satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores, 24 Vet. App. at 97-103; Quartuccio, 16 Vet. App. 183. Also keep in mind that this claim arose in the context of the Veteran trying to establish his underlying entitlement to service connection for his bilateral plantar fasciitis, which since has been granted. When, as here, a claim for service connection has been substantiated and an initial rating and effective date assigned, the filing of a Notice of Disagreement (NOD) with the RO's decision regarding the initial rating or effective date, in other words, as concerning these "downstream" issues, does not trigger additional 38 U.S.C.A. § 5103(a) notice. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). See also Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007). In this circumstance, according to the holding in Goodwin and its progeny, instead of issuing an additional VCAA notice letter in this situation concerning the downstream disability rating or effective date element of the claim, the provisions of 38 U.S.C.A. § 7105(d) require VA to issue an SOC if the disagreement is not resolved, and this occurred in this particular instance. VA's duty to assist under the VCAA includes helping the claimant obtain relevant records, including service treatment records (STRs) and other pertinent records, such as concerning evaluation he has received since service from VA and privately, as well as providing an examination or obtaining a medical opinion when necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). Here, to this end, the Veteran's STRs, Social Security Administration (SSA) records, post-service VA and private medical records, and vocational rehabilitation reports have been obtained and associated with the claims file for consideration. He has not identified any outstanding records that he wants VA to obtain or that he believes are relevant to his claim in terms of showing his entitlement to a greater level of compensation. Therefore, the duty to assist him in obtaining pertinent records has been satisfied. See 38 C.F.R. § 3.159(c). The duty to assist also, as mentioned, includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on a claim. See 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. §§ 3.159(c)(4), 3.326(a), 3.327 (2013); McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the claimant's disability and such is relevant to the claim, a new VA examination must be conducted. See 38 C.F.R. §3.327(a); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). However, unless the claimant challenges the adequacy of the examination or opinion, the Board may assume the examination report and opinion are adequate and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011) (holding that although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-91 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Id. Indeed, even when the claimant challenges a VA examination or opinion, the Board may assume the competency of the VA medical examiner, including nurse practitioners, as long as, under 38 C.F.R. § 3.159(a)(1), he or she is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). Here, VA examinations were performed in November 2004 and February 2012. The examinations, especially when considered in combination, are adequate for rating purposes, as the examiners reviewed the claims file for the history of this disability, examined the Veteran personally, and described his disability in sufficient detail to enable the Board to make a fully informed decision regarding its severity in relation to the applicable rating criteria. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). There are no apparent inconsistencies or ambiguities in the examination reports, and the Veteran has not specifically challenged their adequacy or thoroughness, or the competence of the examiners. See Sickels, 643 F.3d at 1365-66; Rizzo, 580 F.3d at 1290-91. The Veteran equally has not alleged, and there is no evidence suggesting, that there has been a material change in the severity his bilateral plantar fasciitis since he was last examined in February 2012. See 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the mere passage of time since an otherwise adequate VA examination was performed. Palczewski v. Nicholson, 21 Vet. App. 174 (2007); VAOPGCPREC 11-95 (April 7, 1995). Accordingly, VA's duty to assist with respect to obtaining a VA examination has been met. 38 C.F.R. § 3.159(c)(4); Barr, 21 Vet. App. at 312. In sum, VA's duties to notify and assist under the VCAA have been satisfied. The Veteran has had ample opportunity to participate effectively in the development of this claim. See Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011) (citing Overton v. Nicholson, 20 Vet. App. 427, 435 (2006) (finding that any error depriving a claimant of "a meaningful opportunity to participate effectively in the processing of his or her claim . . . must be considered prejudicial")). Any defect in the notice or assistance provided will not affect the outcome of this claim or compromise the "essential fairness of the adjudication," and no such defect has been shown. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). To the contrary, the Veteran has received all essential notice and assistance, has had a meaningful opportunity to participate effectively in the development of this claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Thus, any error in the notice or assistance provided was harmless, again, meaning nonprejudicial. See Shinseki v. Sanders, 556 U.S. 396, 407, 410 (2009) (holding that the "rule of prejudicial error" requires a case-by-case determination as to whether the error in question was harmless, and that it is the burden of the claimant to show the error was harmless by at least providing an explanation as to how the error caused harm); see also 38 U.S.C.A. § 7261(b)(2) and 38 C.F.R. § 20.1102. Accordingly, the Board may proceed with appellate review of this claim. III. Legal Criteria Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule). The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). All reasonable doubt material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 4.3 (2013). Where entitlement to compensation already has been established and increase in disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). But in assessing the present level of disability, VA must determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged" rating. See Fenderson, 12 Vet. App. at 125-26 (first applying this practice in the initial-rating context). But see also Hart v. Mansfield, 21 Vet. App. 505 (2008) (since extending this practice even to established ratings). This change in rating, over time, compensates the Veteran for this varying degree of severity of his disability. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and, above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether the Veteran raised them, as well as the entire history of his disabilities in reaching its decision. Schafrath, 1 Vet. App. 589. Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). IV. Analysis The Veteran maintains that additional compensation is warranted for his plantar fasciitis, especially since it is bilateral, meaning affecting both feet, rather than unilateral, meaning only or just one. In the December 2004 decision at issue in this appeal, the RO granted service connection for the bilateral plantar fasciitis and assigned an initial 10 percent rating for it retroactively effective from April 30, 2004, the day following the Veteran's separation from active duty. The RO has rated this disability under DC 5299-5276. In the assignment of DC numbers, hyphenated DCs may be used. Injuries generally will be represented by the number assigned to the residual condition on the basis of which the rating is determined. Diseases will be identified by the number assigned to the disease itself, followed by a hyphen, with the residual condition listed last. So a hyphenated DC reflects a rating by analogy. See 38 C.F.R. §§ 4.20 and 4.27. DC 5276 pertains to acquired flatfoot. According to this code, a 0 percent (i.e., noncompensable) evaluation is assigned when there is evidence of mild pes planus with symptoms relieved by built-up shoe or arch support. A 10 percent evaluation is assigned when the evidence shows moderate bilateral pes planus with weight-bearing line over or medial to great toe, inward bowing of the tendo Achilles, and pain on manipulation and use of the foot. A 30 percent evaluation is assigned for severe bilateral pes planus with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. A 50 percent evaluation is assigned for pronounced bilateral pes planus with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, DC 5276. DC 5284 provides for evaluating "other" foot injuries as 30-percent disabling if severe, 20 percent if moderately severe, and 10 percent if moderate. With actual loss of use of the foot, a 40-percent rating is warranted. 38 C.F.R. § 4.71a, DC 5284. These descriptive words such as "slight" (or "mild"), "moderate," "moderately severe," and "severe" are not defined in VA's Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. §§ 4.2, 4.6. During his November 2004 VA compensation examination, the Veteran reported he had a diagnosis of bilateral plantar fasciitis and had pain in his arches when he first began to take steps after having been off his feet. He stated he used arch supports without any benefit. The examiner observed that he had a normal pattern gait and did not use any assistive devices. The examiner confirmed the diagnosis of bilateral pes planus without pronation. He observed that there were no bony or soft tissue swellings or deformities, and that the Veteran's Achilles tendons were normally aligned bilaterally, although he did have tenderness to palpation under the arches bilaterally. Halluces showed active and passive dorsiflexion to 45 degrees and active and passive plantar flexion to 30 degrees bilaterally, without any evidence of weakened movement against resistance. VA treatment records reflect normal X-ray findings of both feet in September 2008. April 2009 records reflect the Veteran was given orthotics for his condition. During his August 2011 hearing before the Board, the Veteran testified that, unless he wore tennis shoes, he felt a "snapping like motion" in the bottom of his feet that was worse on the left side. He also stated it was difficult to walk, and again reported that orthotics did not provide much relief. When reexamined by VA for compensation purposes in February 2012, the Veteran reported pain on use of both feet. He did not have pain on manipulation of either feet, swelling on use, characteristic calluses on either feet, or extreme tenderness of the plantar surface of either foot. The examiner noted that the Veteran's symptoms were relieved by arch supports or orthotics, but he also noted that both feet remained symptomatic despite arch supports or orthotics. Physical examination was negative for signs of decreased longitudinal arch height on weight-bearing bilaterally, objective evidence of deformity of either foot, marked pronation of either foot, "inward" bowing of the Achilles tendon, and marked inward displacement and severe spasm of the Achilles tendon on manipulation. While his weight-bearing line was over or medial to the great toe on both sides, there was no lower extremity deformity other than pes planus causing alteration of the weight bearing line. The Veteran reported using a cane regularly and wearing orthotics, but he did not have either on the day of that examination. The examiner indicated the Veteran's feet at the time of that evaluation were within normal limits. He did not have foot deformity, excessive pronation, calluses, extreme tenderness, or swelling of either foot. X-rays of his right foot were normal. Left foot X-rays showed osteoarthritis at the first metatarsophalangeal joint, which the examiner said could be the result of the normal aging process and was not related to the diagnosis of plantar fasciitis. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (VA adjudicators must be able to distinguish or differentiate by competent and credible evidence the extent or measure of symptoms that is attributable to the service-connected disability from that which is not, but instead the result of other factors or causes. If it is not possible to make this distinction, then VA adjudicators must resolve this reasonable doubt in the Veteran's favor, according to 38 C.F.R. §§ 3.102 and 4.3, and for all intents and purposes presume the symptoms and impairment in question are attributable to the service-connected disability.). Here, after reviewing all of the relevant evidence and contrary to its prior decision, the Board has concluded that the Veteran's bilateral plantar fasciitis warrants separate 10 percent ratings - meaning a rating for each foot under DC 5284 rather than just a single, collective rating. DC 5284 contemplates the extent and severity of his bilateral foot pain, which the record shows causes pain on use, and in particular while walking. However, the record does not show that his bilateral plantar fasciitis warrants a higher 20 percent rating for foot injuries deemed "moderately severe" or an even higher 30 percent rating for those deemed "severe." The record since initiation of this claim is devoid of any diagnosis of, at the very least, a "moderately severe" foot injury. His first VA examination in November 2004 was predominantly normal, other than complaints of pain in his arches and non-relief from arch supports. The second and more recent February 2012 examination showed his feet were within normal limits, other than reports of pain on use of them, use of a cane regularly, and conflicting reports regarding the efficacy of orthotics. His feet also were largely unremarkable on X-ray during that evaluation. His symptoms could also be rated under DC 5276 for moderate symptoms, as the Board previously did in its August 2013 decision; however , rating under DC 5284 results in a higher rating and thus a greater benefit to him. See 38 C.F.R. § 4.7. And a higher rating under DC 5276 also is not warranted. As explained, a higher 30 percent rating requires severe bilateral involvement, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. Although pain on manipulation was confirmed during his November 2004 examination and pain on use was confirmed during the February 2012 examination, his condition was not manifested by any of the other symptoms noted in the criteria for a 30 percent rating. The reports from his November 2004 and February 2012 VA examinations specifically noted the absence of any swelling, deformity, and callosities, as well. The finding of pain on use or pain on manipulation, alone - since found during different VA examinations - is insufficient to meet the criteria for the higher 30 percent rating under DC 5276. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). Compare with Johnson v. Brown, 7 Vet. App. 95 (1994) (holding that only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). Because of the successive nature of the rating criteria, such that the evaluation for each higher disability rating includes the criteria of each lower disability rating (at least what could be considered most of them), each of the criteria listed in the 30 percent rating must be met in order to warrant such a rating. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). Thus, there is not sufficient basis to assign a rating higher than 10 percent under DC 5276. There has not been indication of the type of impairment contemplated by other DCs, such as malunion or nonunion of tarsal or metatarsal bones or claw foot, to warrant their application. See 38 C.F.R. § 4.71a, DCs 5277-5283. Throughout the rating period on appeal, there is no evidence of record indicating the Veteran's feet are deformed. His feet were closely examined during his VA examinations and during VA outpatient treatment sessions, and at no point has an examiner noted a foot deformity. Moreover, deformities were not shown on X-rays of the feet taken during the pendency of the appeal. Consideration has been given to assigning a staged rating; however, at no time during the period in question has the disability warranted a higher schedular rating. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Therefore, an initial 10 percent rating - albeit for each foot - is warranted under DC 5284 because the Veteran has bilateral, not just unilateral, plantar fasciitis, but the evidence does not warrant any higher rating under any relevant DC. V. Extra-schedular Consideration Referral of this claim for extra-schedular consideration also is not warranted. See 38 C.F.R. § 3.321(b) (2013); Thun v. Peake, 22 Vet. App. 111, 114 (2008). Because the ratings provided under the VA Rating Schedule are mere averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun, 22 Vet. App. at 114. However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extra-schedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). In Thun, 22 Vet. App. at 115, the Court held that the determination of whether a claimant is entitled to an extra-schedular rating under 38 C.F.R. § 3.321(b) is a three-step inquiry. First, as a threshold factor, there must be a finding that the evidence of record presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. In this regard, the Board must compare the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the Rating Schedule for that disability. See id. If the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Id. Second, if the schedular criteria are found to be inadequate to evaluate the claimant's disability, the Board must determine whether the exceptional disability exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. If so, then under the third step of the inquiry the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. Referral for extra-schedular consideration is not warranted for this disability at issue, however. A comparison of the Veteran's service-connected bilateral plantar fasciitis and associated symptoms with the rating criteria do not show "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). His bilateral plantar fasciitis is manifested by symptoms and functional impairment expressly addressed by the rating criteria, including especially pain on use of his feet. His symptoms and functional limitations are contemplated by, and indeed directly addressed in, sections 4.40, 4.45, and 4.59 of the regulations, as well as the relevant DCs, which provide for compensation for painful and limited motion. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Burton v. Shinseki, 25 Vet. App. 1 (2011); and DeLuca v. Brown, 8 Vet. App. 202 (1995). In Mitchell, the Court held that the evaluation of painful motion as limited motion only applies when limitation of motion is 0-percent disabling, i.e., noncompensable, under the applicable DC. The Court further explained that, although painful motion is entitled to a minimum 10 percent rating under Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991), when read together with DC 5003 concerning arthritis, it does not follow that the maximum rating is warranted under the applicable DC pertaining to range of motion simply because pain is present throughout the range of motion. See id. Therefore, the Board finds that the Veteran does not have any symptoms or functional limitations not accounted for in the ratings assigned under the schedular criteria. See Thun, 22 Vet. App. at 115. There is no evidence suggesting that the Veteran's specific functional limitations, including with regard to pain, are exceptional or unusual given the symptoms and functional impairment already compensated under the rating criteria. Thus, such functional impairment is within the purview of the Rating Schedule even if not specifically mentioned in the applicable DCs. Indeed, the schedular criteria generally do not set forth specific examples of functional impairment with regard to musculoskeletal disorders. See 38 C.F.R. § 4.1 (providing that the degrees of disability specified in the General Rating Criteria are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability); see also 38 C.F.R. § 4.21 (2013) (providing that "[c]oordination of rating with impairment of function will . . . be expected in all instances"). As noted in Thun, 22 Vet. App. at 114, the rating criteria are averages and need not account for each individual circumstance in order to be adequate for evaluation purposes. Therefore, as the evidence does not show that the Veteran's bilateral plantar fasciitis is "exceptional" or "unusual" when compared with the rating criteria, the available schedular evaluations are adequate for rating purposes. Accordingly, the first prong of the three-part Thun test is not satisfied. See id. In the absence of this threshold finding, there is no need to consider the second step of the inquiry, namely, whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See id. at 118-19 (holding that the Board's "threshold" finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extra-schedular consideration without regard to whether there was marked interference with employment). Indeed, in the absence of an exceptional or unusual disability picture under the first Thun factor, interference with employment is not sufficient by itself to warrant extra-schedular referral, as the rating schedule "clearly recognizes that the rated disabilities interfere with employment." See VAOPGCPREC 6-96 (August 16, 1996). See also 38 C.F.R. §§ 4.1, 4.15. Consequently, referral for extra-schedular consideration is not warranted. Id. ORDER Separate 10 percent initial ratings are granted for the bilateral plantar fasciitis (meaning a 10 percent initial rating for each foot, rather than just a single, collective rating at this level), subject to the statutes and regulations governing the payment of VA compensation. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs